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How should a healthcare professional assess for fluid overload in a patient with heart failure?
- A. Monitor daily weight
- B. Check for edema
- C. Monitor blood pressure
- D. Check oxygen saturation
Correct Answer: A
Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.
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A client with diabetes mellitus is being taught by a nurse on managing hypoglycemia. Which of the following instructions should the nurse include?
- A. Avoid consuming carbohydrate-rich foods.
- B. Consume 15 grams of a fast-acting carbohydrate.
- C. Drink a glass of water to raise blood glucose levels.
- D. Eat a snack before exercising to prevent hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Consume 15 grams of a fast-acting carbohydrate. Consuming 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, helps raise blood glucose levels quickly in cases of hypoglycemia. Choice A is incorrect because avoiding carbohydrate-rich foods during hypoglycemia can worsen the condition. Choice C is incorrect as drinking water does not effectively raise blood glucose levels. Choice D is incorrect as eating a snack before exercising is more related to preventing exercise-induced hypoglycemia, not managing hypoglycemia.
A client has a new prescription for levothyroxine. Which of the following instructions should the nurse include?
- A. Take this medication in the evening before bed.
- B. Take this medication on an empty stomach.
- C. Take this medication with a full glass of milk.
- D. Take this medication with an antacid if you experience indigestion.
Correct Answer: B
Rationale: The correct instruction when taking levothyroxine is to take it on an empty stomach. This enhances absorption and ensures the medication's effectiveness. Taking it with food or other substances, such as milk or antacids, can interfere with its absorption. Therefore, choices A, C, and D are incorrect.
Which of the following is a sign of digoxin toxicity?
- A. Bradycardia
- B. Hypertension
- C. Tachycardia
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A, Bradycardia. Bradycardia, or a slower than normal heart rate, is a classic sign of digoxin toxicity. Digoxin is a medication commonly used to treat heart conditions, but an excess of digoxin in the body can lead to toxicity. This toxicity can manifest as various symptoms, with bradycardia being one of the most common ones. Hypertension (high blood pressure) and tachycardia (fast heart rate) are not typical signs of digoxin toxicity. Tachypnea, which refers to rapid breathing, is also not a common sign of digoxin toxicity.
A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?
- A. Place the client in seclusion when she is confused.
- B. Request a prescription for PRN restraints when the client is wandering.
- C. Dim the lighting in the client's room.
- D. Leave one side rail up on the client's bed.
Correct Answer: C
Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the priority for the nurse to report?
- A. Calcium level of 9.0 mg/dL
- B. Serum sodium level of 138 mEq/L
- C. Respiratory rate of 18/min
- D. Stridor
Correct Answer: D
Rationale: Stridor is a high-pitched sound that indicates airway obstruction and is the priority finding to report following a thyroidectomy. In this situation, airway compromise is a critical concern that requires immediate intervention to ensure adequate oxygenation. While calcium level (Choice A) and serum sodium level (Choice B) are important assessments post-thyroidectomy, they do not represent an immediate threat to the client's airway. A respiratory rate of 18/min (Choice C) falls within the normal range and does not indicate an immediate risk to the client's airway compared to the presence of stridor.